Susan Templeman Cocktail Party Reservation_Form

Reservation Form Susan Templeman Cocktail Party

Date: Monday 20th May 2013 Time: 6 – 8pm Venue: The Belvedere Hotel, Lvl 1, 482 Kent St (cnr Bathurst), Sydney Special Guest: Clare Martin, former Chief Minister of Northern Territory RESERVATION FORM AND TAX INVOICE Please complete all details below and return the form with payment by Wednesday 16th May to or Helen Westwood PO Box 537 Concord 2137 Name Organisation Address Phone Email PAYMENT – Please indicate how many tickets you are purchasing. Please note payment must be received to confirm your registration. Seven days notice is required for cancellations and refunds. Price includes GST. Tickets @ $80 or $70 concession Please debit my: For $ Name on card Card Number Expiry Date Signature on card Date: ____________ For payment by cheque, please make payable to: NSW ALP – Federal Campaign Account The below declaration must be completed for this reservation to be accepted.
I confirm that this donation is not made by or on behalf of a ‘prohibited donor’ (being a ‘property developer’, ‘tobacco industry business entity’ or ‘liquor or gambling industry business entity’), or a ‘close associate’ of a ‘prohibited donor’, as defined in Division 4A of Part 6 of the Election Funding, Expenditure and Disclosures Act 1981 (NSW).


Please receipt Amex Diners





Name Signature Date
This document will be a tax invoice for GST purposes when you make full payment. Please retain a copy for your records. Australian Labor Party NSW Branch ABN 36 192 855 036

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